Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Folsom, California 95360
Saturday, July 13, 1996 11:52 PDT
NTSB Narrative Summary Released at Completion of Accident
The aircraft was in cruise flight when the pilot noticed the oil pressure rapidly decrease, followed shortly thereafter by engine roughness. With a loud knock, the engine lost power and oil began to spray on the windshield. The aircraft collided with ground obstructions during a forced landing attempt on a road. Disassembly of the engine revealed only trace amounts of oil in the case, with a typical oil starvation heat distress failure of the numbers 3 and 4 connecting rods. During removal of the propeller governor only a MS9144-01 screen gasket was installed between the governor and the mounting pad. An oil path was observed running between the gasket and the pad from the high pressure oil port to the outside edge of the pad. Review of Lycoming publications (published in 1987) revealed that this particular engine requires a unique gasket and plate stack to prevent oil leakage between the governor and it's mounting pad. The maintenance records disclosed that 1.4 hours prior to the accident, the propeller governor was removed for repair then reinstalled on the engine. Both the mechanic who performed the work and the IA who inspected the job stated that the current Cessna 177 maintenance and parts manuals were used for procedural guidance. Both said they were unaware of a special gasket stack requirement for this particular engine, and they would not routinely refer to engine manuals for a governor installation since the governor is an airframe component. The Cessna service manual only speaks to the installation of the MS screen gasket, and uses the term 'gasket' in the singular form. The special Lycoming gasket and plate are not mentioned in either Cessna manual. Cessna Aircraft stated that they were aware of the Lycoming requirement for a special gasket stack for the Cessna 177RG aircraft application and are in the process of revising the Service and Parts manuals accordingly.
NTSB Probable Cause Narrative
An oil starvation failure of the engine due to a mechanic's failure to put the proper gasket stack on when the propeller governor was replaced. The mechanic's omission was due to the airframe manufacturer's failure to ensure that the service and parts manuals for the aircraft contained the most recent information concerning the unique gasket requirement for this airplane.
Event Information
| Type of Event | Accident |
| Event Date | 7/13/1996 |
| Event Day of the Week | Saturday |
| Time of Event | 1152 |
| Event Time Zone | Pacific Daylight Time |
| Event City | FOLSOM |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 95360 |
| Event Date Year | 1996 |
| Event Date Month | 7 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | |
| Event Location Nearest Airport ID | |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | -- |
| Weather Briefing Completeness | Unknown |
| Investigator's weather source | Pilot |
| Time of the weather observation | 0 |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | |
| Elevation of weather observation facility | 0 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 1000 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 20 |
| Air Temperature at event time (in degrees celsius) | 31 |
| Dew Point at event time (in degress fahrenheit) | 14 |
| Wind Direction (degrees magnetic) | 0 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 0 |
| Wind Velocity Indicator | Light and Variable |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 29 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 2 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 805 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Jul 13 1996 12:00AM |
| NTSB Notification Time | 1232 |
| Fiche Number and/or location -used to find docket information | IMAGE |
| Date of most recent change to record | Dec 8 2000 10:12AM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N52185 |
| NTSB Number | LAX96LA270 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Cessna |
| Aircraft Model | 177RG |
| Aircraft Series Identifier | 177RG |
| Aircraft Serial Number | 177RG1187 |
| Certified Max Gross Weight | 2800 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | 100 Hour |
| Date of Last Inspection | Jun 28 1996 12:00AM |
| Airframe hours since last inspection | 28 |
| Airframe Hours | 3869 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | KENNETH W. HALL |
| Aircraft Owner Street Address | 37874 LOS ARBOLES DRIVE |
| Aircraft Owner City | FREMONT |
| Aircraft Owner State | CA |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 94536 |
| Operator is an individual? | -- |
| Operator Name | CALIFORNIA AIRWAYS |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 1164 W. A STREET |
| Operator City | HAYWARD |
| Operator State | CA |
| Operator Country | |
| Operator Zip code | 95360 |
| Operator Code | |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Personal |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | HWD |
| Departure City | HAYWARD |
| Departure State | CA |
| Departure Country | |
| Departure Time | 1109 |
| Departure Time Zone | PDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | Q61 |
| Destination City | GEORGETOWN |
| Destination State | CA |
| Destination Country | |
| Specific Phase of Flight | Cruise |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |